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Which statement indicates to the nurse the client is experiencing some hearing loss?
- A. I clean my ears every day after I take a shower.
- B. I keep turning up the sound on my television.
- C. My ears hurt, especially when I yawn.
- D. I get dizzy when I get up from the chair.
Correct Answer: B
Rationale: Turning up the television volume suggests hearing loss. Ear cleaning is unrelated, ear pain suggests infection, and dizziness indicates vestibular issues.
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When planning care for a woman with myasthenia gravis, the nurse asks her what time of day she feels strongest. The nurse would expect which of the following replies?
- A. I can wash up and comb my hair before breakfast because I feel best in the morning.'
- B. I only feel good for about an hour after I take my medication.'
- C. I feel strongest in the evening, so I would prefer to take a shower before bedtime.'
- D. I feel best after lunch after I've been moving around a little.'
Correct Answer: A
Rationale: Muscle strength in myasthenia gravis is typically best in the morning, with weakness worsening throughout the day.
The client has an hordeolum of the left eye, which is painful. Which intervention, if prescribed, should the nurse implement?
- A. Apply an eye patch on the left eye.
- B. Insert miotic eye drops twice daily.
- C. Apply a warm compress four times daily.
- D. Administer an antibiotic intravenously.
Correct Answer: C
Rationale: Warm compresses are applied to promote drainage of the hordeolum. Patching is not indicated, miotic drops treat glaucoma, and IV antibiotics are unnecessary as topical antibiotics are used.
The nurse is administering eye drops to a client. Which action is correct?
- A. Ask the client to report any blurring of vision and difficulty focusing that occurs after the administration of eye drops.
- B. Apply gentle pressure to the nasolacrimal canal for one to two minutes after instillation to prevent systemic absorption.
- C. Have the client lie down with eyes closed for 45 minutes after giving drops.
- D. Gently pull the lower lid down and place medicine in the center of the eye.
Correct Answer: B
Rationale: Applying pressure to the nasolacrimal canal prevents systemic absorption of eye drops, enhancing safety and efficacy.
An adult man fell off a ladder and hit his head and lost consciousness. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. The nursing care plan will most likely include which of the following?
- A. Elevate head of bed 15 to 30 degrees
- B. Encourage fluids to 1000 mL every eight hours
- C. Assist the client to cough and deep breathe every two hours
- D. Perform chest physical therapy every four hours while awake
Correct Answer: A
Rationale: Elevating the head of the bed 15 to 30 degrees promotes gravity drainage of fluid and reduces cerebral edema. Coughing, forcing fluids, and chest physical therapy may increase intracranial pressure and are contraindicated.
The nurse is caring for a client who has recently had a cerebrovascular accident (CVA). When positioning the client and supporting her extremities, the nurse must remember that when voluntary control of muscles is lost:
- A. the feet will maintain a position of eversion.
- B. the upper extremities will rotate externally.
- C. the hip joint will rotate internally.
- D. flexor muscles will become stronger than extensors.
Correct Answer: D
Rationale: After a CVA, flexor muscles become stronger than extensors, leading to flexion contractures, requiring careful positioning to prevent deformities.